RECOMMENDATIONS:
POST-TRAUMATIC STRESS DISORDER

I.  ABILITY RECOMMENDATIONS

1. Children with PTSD often show some deficits with respect to general fund of knowledge.  In response, ability interventions that focus on enhancing and expanding the child’s knowledge base is generally recommended.  Provision of daily reading time (30+ minutes per day) may be particularly beneficial with initial readings on preferred subjects and expanding to include current events (i.e.., newspaper, local magazines, etc.).

II. SKILL RECOMMENDATIONS

2. Children with PTSD often show lags in academic achievement along with a discrepancy between native intelligence (higher) and academic achievement (lower).  In the absence of a defined learning disability, this lag is generally related to the persistent stress-related “fight or flight” responses with greatest negative effects upon “pyramid” subjects (i.e.., subjects in which today’s lesson is based on the foundation provided during yesterday’s lecture).  In response, recommendations generally focus on provision of daily reading time to enhance vocabulary/knowledge base, provision of resource-type classes in school during which previously-learned materials may be reviewed, initiation of tutoring (or summer school) to identify specific areas of lag and 1:1 instruction to increase the rate of learning.

3. According to the Task Difficulty vs. Performance Relationship (Yerkes-Dobson Law), children tend to exhibit maximal performance (and minimal frustration) when tasks are of moderate difficulty.  Under very high (“too hard”) or very low (“too easy”) task demands, performance tends to be very poor with associated high levels of frustration.  While identification of the appropriate level of task difficulty for an individual child is challenging, the problem (i.e.., identifying the “proper” task difficulty) is magnified among children with PTSD since their frustration level is already elevated and skill levels tend to be uneven.  The general rule is that high levels of child frustration or child anger (externalized distress) are indicative of a need to lower task difficulty by either reducing the complexity of the problem or by “cutting” the task into a set of smaller and more easily completed tasks. 

III. COPING RESOURCE RECOMMENDATIONS

1. Children with PTSD commonly have histories of internalizing coping skills based on inadequate, dysfunctional or abusive parent (“other”) models and, as a result, often share similar deficient coping skills.  In response, utilization of a cognitive-behavioral approach is recommended to facilitate development of effective coping skills sufficient to manage existing drive/distress.  Specific cognitive-behavioral therapy components include: (a) increasing self-observer functions by labeling emotions (i.e.., “it looks like you are feeling…”) to assist the child in articulation of negative emotions, (b) providing cues/assistance in identification of antecedents or triggers for negative emotions (i.e.., “when did you begin to feel that way?  where were you?, etc.) to assist in identification of trigger zones or antecedents, (c) learning to identify that behaviors are choices (i.e.., “what did you choose to do with those negative emotions?”) to enhance higher level executive or “coaching” contributions to behavior, (d) assistance in identification of outcomes (i.e.., “how did that work out for you?”) to facilitate self-observation and utilization of feedback, (e) assistance in recognition of the extent to which outcomes influenced triggers (“did those outcomes change the triggers?”) to avoid vicious cycles in which behaviors have no impact on the triggers and (f) encouraging development of alternative strategies (i.e.., “what might you do differently next time?”) to enhance expansion of the child’s repertoire or range of coping skills.  Existing research indicates that cognitive-behavioral therapy (CBT) – type interventions are among “what works” among children involved in juvenile probation.  Parental instruction in the use of these techniques is often very important.
   
   
2. While uncovering abusive events has been found to be critical to long-term healing, treatment emphasis must begin with present moment coping skills.  Use of Cognitive-Behavioral Strategies (above) may be particularly beneficial in building present moment coping skill.  Only after day-to-day stressors are effectively managed is it reasonable to undertake the “hero’s journey” into the uncovering of past trauma.  It is critical that this uncovering process occurs within the context of safe relationships.  Initial uncovering type therapy often begins with identification of “keys” or triggers that are reliably associated with elevated distress or flashbacks.  Recording of keys/triggers (i.e.., use of diary to record “bad” days including references to antecedents) is often undertaken to assist in unraveling the story. 
   
   
3. Uncovering-type therapies tend to be arduous due to the fact that repressed primitive or negative emotions tend to be stored in impressions, sensory images and emotions with few words.  As a result, attempts to utilize words to uncover nonverbal emotions tend to be fruitless.  In response, uncovering often requires some degree of “hypnosis-like” inductions, EMDR or judicious use of keys to recreate the “scene” including sights, sounds, smells, tactile sensations, etc. associated with trauma.  Utilization of a guide in the form of a therapist is strongly recommended.  Skeleton Woman (see Women Who Run with Wolves, Clarissa Pinkola-Estes) also may serve as a companion or guide to the process as the individual begins to confront “lost parts”. 
   
   
4. Children with PTSD tend to have histories of exposure to home environments that are not safe, secure, structured or predictable.  In response, interventions of some benefit tend to focus on enhancing safety, security, structure and predictability.  Safety interventions simply indicate that the child should always be in safe situations.  Monitoring the child in novel situations is critical to insuring safety.  Security tends to be fostered by exposure to “others” (adult, parent, etc.) that live a life of integrity (i.e.., saying what you do and doing what you say).  Structure tends to be enhanced by maximizing structure across space (i.e.., organize room, backpack, desk, etc.) and time (i.e.., calendar, schedule, routine, etc.).  Finally, predictability tends to be enhanced by use of schedules and consistent rules/consequences. 
   
   
5. Children with PTSD tend to experience disinhibited behaviors or distress responses (“fight or flight”) that exceed the intensity and duration of peers.  Under conditions in which disinhibited behaviors are not avoided using other interventions (suggested above), it is recommended that the disinhibited behaviors be addressed using an approach that has been labeled “Safe Place”.  “Safe Place” represents a step-by-step hierarchy of interventions that focus on reducing potential threats that fuel the behavior.  Each step in the process is under-taken only if success (defined by a reduction in distress responses) is not achieved by the previous step.  “Safe Place” interventions include:
   

1. stepping back, dropping to a similar eye level (i.e.., having to look up or high visual angle is a threat), showing palms and quietly asking the child questions (avoiding “why?”) to engage higher level processing (i.e.., “what just happened?, when did it happen? where did it happen?)
2. identifying the child’s behaviors as not being safe (i.e.., “it looks like you are not safe right now”)
3. asking the child to retreat to a safe and secure environment (i.e.., previously-agreed upon safe place such as a bedroom, basement, porch, favorite place, etc.) with a suggestion to return when “things are going better”
4. telling the child that you may need to help them retreat to their safe place
5. informing the child that you will be touching them in order to assist them into their safe place
6. following transition to a safe and secure environment, the child should be provided with about 20-30 minutes to shift from an arousal state to higher level voluntary control before progressing with a “post-mortem” analysis (cognitive-behavioral review above). 

IV. MEDICAL CONSIDERATIONS

Children with PTSD profiles often show some benefits to medications that “turn down the volume” of distress levels and associated activation.  Studies have shown that dopaminergic blocking agents (antipsychotics), partial dopaminergic / D2 agonists and medications that increase serotonin availability tend to result in overall “dampening” of activation (i.e.., limbic system) with associated benefits to adaptation.  No specific standard of practice has been unanimously identified by the psychiatry community.  However, initial interventions often focus on use of SSRI agents alone.  The SSRI effect has been associated with some degree of down regulation of “fight or flight” responses.  Under conditions in which SSRI agents have limited or short-term benefits, treatment using combination medications with both dopaminergic and seratonergic (increase) properties (i.e.., Abilify, Risperdal, etc.) has been found to be beneficial among some children.  Issues regarding medications need to be addressed with the child’s attending physician or psychiatrist to assist in evaluation of potential costs and benefits of treatment.